The Healing Journey Registration
A 10-Week Online Facilitator-Led Grief & Loss Program
Full Name
*
Date of birth
*
Gender
*
Email Address
*
Phone
*
Address
Street Address
City
State
Country
Country
Postal Code
Martial Status
Loss History
*
Spouse/Partner
Parent
Child
Sibling
Friend
Other
Who did you lose?
Date of Loss
*
Cause of Loss
If you are comfortable sharing
Racial or Ethnic Group
*
African American / Black
Hispanic / Latino/a/x
Asian / Asian American
Native American / Indigenous
White / Caucasian
Multiracial / Biracial
Other
Prefer Not to Answer
Religious Affiliation (if any)
Christian
Jewish
Muslim
Hindu
Buddhist
Other faith/spiritual practice
None
Prefer Not to Answer
If Christian please specify denomination / If Other please specify practice
What brings you to the Healing Journey program?
*
What do you hope to gain or experience through this program?
*
Are you currently receiving counseling/therapy?
*
Yes
No
Do you have a strong support system (friends/family)?
*
Yes
No
Any concerns or special needs we should be aware of?
*
Emergency Contact
*
Emergency Contact Phone
*
Emergency Contact Relationship
*
Consent & Agreement
*
I understand this program is for support and education, not therapy or medical treatment.
I agree to respect the confidentiality of others.
I consent to participate in group activities and discussions.
Signature
*
Clear
Date
*
Submit Registration